Abscess Formation After Tooth Extraction: A Long-Term Complication of Polyacrylamide Hydrogel Filler.

A 35-year-old woman with a history of polyacrylamide hydrogel filler injection was referred with a fluctuating facial abscess after decayed tooth extraction. MRI imaging confirmed the diagnosis of an abscess. After appropriate treatment, the patient healed with a little hyperpigmentation and deformity in the zygomaticotemporal area. Although polyacrylamide hydrogel filler injection is considered non-toxic, non-immunogenic, and biocompatible; as a permanent material, physicians should be aware of the risk of its late complications such as late infections. In addition to antiseptic measures, antibiotic prophylaxis may be necessary before the procedures which have a risk of bacteremia and close to the permanent filler location.

Labia Majora Augmentation with De-epithelialized Labial Rim (Minora) Flaps as an Auxiliary Procedure for Labia Minora Reduction.

BACKGROUND: Esthetic surgery of external female genitalia remains an uncommon procedure. This article describes a novel, de-epithelialized, labial rim flap technique for labia majora augmentation using de-epithelialized labia minora tissue otherwise to be excised as an adjunct to labia minora reduction. METHODS: Ten patients were included in the study. The protruding segments of the labia minora were de-epithelialized with a fine scissors or scalpel instead of being excised, and a bulky section of subcutaneous tissue was obtained. Between the outer and inner surfaces of the labia minora, a flap with a subcutaneous pedicle was created in continuity with the de-epithelialized marginal tissue. A pocket was dissected in the labium majus, and the flap was transposed into the pocket to augment the labia majora. RESULTS: Mean patient age was 39.9 (±13.9) years, mean operation time was 60 min, and mean follow-up period was 14.5 (±3.4) months. There were no major complications (hematoma, wound dehiscence, infection) following surgery. No patient complained of postoperative difficulty with coitus or dyspareunia. All patients were satisfied with the final appearance. CONCLUSION: Several methods for labia minora reduction have been described. Auxiliary procedures are required with labia minora reduction for better results. Nevertheless, few authors have taken into account the final esthetic appearance of the whole female external genitalia. The described technique in this study is indicated primarily for mild atrophy of the labia majora with labia minora hypertrophy; the technique resulted in perfect patient satisfaction with no major complications or postoperative coital problems. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Freestyle Perforator-Based Fasciocutaneous Flap Reconstruction in Nicolau Syndrome-Related Tissue Necrosis.

The actual pathology of the Nicolau syndrome (NS) is still unknown. It is thought to involve direct vascular damage and vasospasm. Many NS cases were reported in the literature but a treatment protocol is still not established. However, after demarcation of the necrotic tissue, surgical intervention is mandatory. Five NS cases with extensive tissue necrosis on the upper lateral gluteal region were analyzed retrospectively. Operative technique was described in details for freestyle perforator-based fasciocutaneous flaps from the gluteal region to reconstruct defects of NS-related tissue necrosis. Freestyle perforator-based fasciocutaneous flaps were used for defect closure in all patients. All flaps survived totally. No complications occurred during the follow-up period. Although rare, NS is a serious complication of inadvertent intramuscular injections. Prevention is the best treatment. However, in case of large-tissue necrosis, freestyle perforator-based fasciocutaneous flaps harvested from the gluteal region is a satisfactory option for reconstruction.

Effects of ischemic preconditioning protocols on skeletal muscle ischemia-reperfusion injury.

BACKGROUND: Ischemic preconditioning (IPC) is described as brief ischemia-reperfusion (I/R) cycles to induce tolerance to subsequent in response to longer I/R insults. Various IPC protocols can be performed in four combinations as follows: at early or late phases and on local or distant organs. Although many experimental studies have been performed on IPC, no consensus has been established on which IPC protocol is most effective. The aims of the present study were as follows: (1) to compare the variables of preconditioning in different combinations (in early versus late phases; local versus remote organ implementations) and (2) to determine the most therapeutic IPC protocol(s). MATERIALS AND METHODS: A subtotal hind limb amputation model with clamping an intact femoral pedicle was used for I/R injury. IPC was induced using hind limb tourniquet with 3 × 10 min I/R cycles before longer I/R insult. Forty-nine rats were divided into seven groups (n = 7), sham, IsO (ischemia only), I/R, early ischemic preconditioning (e-IPC), late ischemic preconditioning (l-IPC), early remote ischemic preconditioning (e-RIPC), and l-RIPC (late-remote) groups, respectively. In the sham group, pedicle occlusion was not performed. Six hours ischemia was challenged in the IsO group. Three hours ischemia followed by 3 h reperfusion was performed in the I/R group. The e-IPC group was immediately preconditioned, whereas the l-IPC group was preconditioned 24 h before I/R injury on the same hind limb. In the e-RIPC and l-RIPC groups, the same protocols were performed on the contralateral hind limb. At the end of the experiments, skeletal muscle tissue samples were obtained for biochemical analysis (Malondialdehyde [MDA], catalase, myeloperoxidase [MPO], and nitric oxide end products [NOx]), light microscopy, and caspase-3 immunohistochemistry for determination of apoptosis. RESULTS: Tissue biochemical markers were improved in nearly all the IPC groups compared with IsO and I/R groups (P < 0.05). Similarly, the histologic damage scores were decreased in all the IPC groups (P < 0.05). The lowest damage score was in the e-RIPC group followed by the l-RIPC, e-IPC, and l-IPC groups, respectively. The apoptosis scores were significantly high in the I/R group compared with the e-RIPC and l-RIPC groups (P < 0.05). Although apoptosis scores of the e-IPC and l-IPC groups were lower than the I/R group, this finding was not statistically significant (P > 0.05). CONCLUSIONS: All IPC protocols were effective in reducing I/R injury. Among these protocols, e-RIPC achieved most protection.

e-Flap nipple reconstruction in amputation mammaplasty.

BACKGROUND: Although widely used in women who have gigantomastia, free nipple graft breast reduction has several disadvantages with respect to the nipple-areola graft. In this report, we present the use of a nipple reconstruction method instead of free nipple grafting. METHOD: Free nipple reduction mammaplasty is performed according to the Wise pattern. The nipple is removed from the areola graft. Nipple reconstruction is done at the most proximal and projected part of the reduced breast, which corresponds to the future nipple site. Afterward, the reconstructed nipple is encircled with the areola graft. RESULTS: A total of 18 patients underwent breast reduction with nipple reconstruction and areola grafting between April 2007 and March 2010. The mean follow-up period was 8 months. With the proposed nipple reconstruction technique, the mean projections of the nipple at the end of the operation and at 6 months were 1.2 and 0.9 cm, respectively. CONCLUSION: The technique of using nipple reconstruction in amputation mammaplasty avoids the problems related to the nipple graft such as loss of projection, loss of sensation, or even total or partial loss of the nipple. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.

Experimental study on axial pedicled composite flap prefabrication with high density porous polyethylene implants: medporocutaneous flap.

Composite flaps including soft tissues with bone or cartilage are widely used in reconstruction of three-dimensional defects, but have some disadvantages. Flap prefabrication with alloplastic implants is an alternative procedure. Axial pattern vascularised high density porous polyethylene (HDPP) implants are capable of sustaining skin grafts. The purpose of this study was to examine the vascularisation pattern of the skin island in a composite flap prefabrication model prepared with vascularised HDPP implants. Forty male Wistar rats divided into four groups were used. A 9.5 x 6 x 2 mm HDPP block was centered on the dissected saphenous pedicle and anchored under the abdominal skin in the experimental group I (n=10). In experimental group II (n=10) saphenous artery and vein were put between the skin and the implant. Thus, the structures were laid as skin, HDPP block, pedicle in experimental group I and skin, pedicle, HDPP block in experimental group II. HDPP block-implanted and pedicle-implanted only groups served as control groups I and II, respectively. Eight weeks after prefabrication, skin islands 1.5 x 5 cm in size incorporated with implants were elevated based on saphenous vessels in the experimental groups and skin islands only based on the pedicle in control group II. Skin islands of the same dimensions were raised as grafts in control group I. Nylon sheets were put under the flaps and grafts to prevent vascularisation from the recipient bed. Flap viability was assessed by measuring the surface area on the 7th day. Total necrosis developed in composite grafts of control group I. Flap survival was higher in experimental group II and control group II (45% and 46.8%) than in group I (29.28%). Histologic studies demonstrated fibrovascular ingrowth into the HDPP implants, except in control group I, with significant inflammatory response and necrosis. Vascularisation of skin and implants from the pedicle was seen also microangiographically. In conclusion, a composite flap prefabrication model including vascularised HDPP implant, skin and vascular carrier was developed. This new flap was termed a 'medporocutaneous flap'.